Provider Demographics
NPI:1629187976
Name:WALLACE, SYLVESTER DARREN (LMSW, ACSW, C-ASWCM)
Entity Type:Individual
Prefix:MR
First Name:SYLVESTER
Middle Name:DARREN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LMSW, ACSW, C-ASWCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7651 HIGHWAY 69 NORTH
Mailing Address - Street 2:APT 815
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-7862
Mailing Address - Country:US
Mailing Address - Phone:205-339-6098
Mailing Address - Fax:
Practice Address - Street 1:3701 LOOP RD
Practice Address - Street 2:SOCIAL WORK SERVICE 122
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5015
Practice Address - Country:US
Practice Address - Phone:205-554-2000
Practice Address - Fax:205-554-3556
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0020751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical